Provider Demographics
NPI:1588396980
Name:FODER, MICHAEL BRIAN JR
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRIAN
Last Name:FODER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 EPIRUS HL
Mailing Address - Street 2:
Mailing Address - City:SOUTH ABINGTON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18411-8898
Mailing Address - Country:US
Mailing Address - Phone:570-351-4011
Mailing Address - Fax:
Practice Address - Street 1:585 EPIRUS HL
Practice Address - Street 2:
Practice Address - City:SOUTH ABINGTON TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18411-8898
Practice Address - Country:US
Practice Address - Phone:570-351-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-26
Last Update Date:2022-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAYYM109523258001OtherHIGHMARK BCBS PPO BLUE